NHS Walsall Clinical Commissioning Group (CCG)

Developing an MSK Together service 2017-2019

RightCare works with local health systems to identify innovative practice and share learning. Information briefs are a way of communicating early views of emerging practice. They are designed to raise interest and demonstrate good practice in the development of transformative change across the country.


  • Musculoskeletal (MSK) was identified as one of Walsall CCG’s three priority programmes, when RightCare started working with the CCG in January 2017.
  • The main challenges were in the osteoarthritis pathway with high numbers of hip and knee replacements yet poor patient outcome measures.
  • The CCG had already implemented policy changes impacting on MSK procedures as part of their Procedures of Low Clinical Value (PLCV) programme.

Diagnose – what’s the problem?

  • The RightCare Delivery Partner worked with the lead commissioner to develop a storyboard presenting the RightCare opportunities.
  • System design workshops were held where the storyboard was presented, then used to gain a shared understanding of the challenges.
  • Current pathways were mapped, ideas for optimal pathways discussed, and options for improvement
  • In May 2017, NHS England published a specification for MSK triage as part of their high impact interventions programme and mandated CCG’s to introduce an MSK triage service by September 30th, 2018.
  • This requirement was incorporated into the RightCare MSK work already underway and the triage service commenced on October 2nd, 2017.
  • This work was translated into a logic model which was submitted in June 2017 and finalised by September 2017.

Develop – what they changed

  • One of the key actions was to merge the physiotherapy and Orthopaedic Assessment Clinical Assessment Service (OCAS) services to create an intermediate MSK service (iMSK), covering both acute and community provision of physiotherapy and other services.
  • The overall iMSK service function is to triage, assess, treat and onward refer the referrals they receive into the service.
  • All referrals from primary care and self-referrals for trauma and orthopaedics, pain clinic (MSK pain only), rheumatology, and spinal service go to this team in the first instance.
  • The iMSK service was implemented quickly and since then work has continued to refine the pathways, particularly the interventions provided by this team.

Deliver – What does the local health system say changed

  • Approximately 1,500 referrals per month are received with only 10% being immediately referred onto secondary care. MSK referrals to secondary care have reduced by 22% (a drop of over 1600 appointments) and follow up appointments by 38% (a drop of nearly 7000 appointments).
  • At least 80% of referrals are dealt with by the new iMSK service.
  • 10% referred to other services such as podiatry, intermediate care team or rejected and returned to GPs.
  • The referral to treatment (RTT) rate for Trauma and Orthopaedics has increased to over 95%.
  • Patient Reported Outcome Measures (PROMs) data shows patient satisfaction with the service.
  • The RightCare opportunity for MSK elective spend has more than halved from over £2.12 million in 2016/17 to £1.03 million in 2017/18.

What next? – learning points from the local system

  • Work with GPs to increase the use of iMSK and ensure only red flags go direct to outpatients.
  • Explore how first contact MSK practitioners can be implemented.
  • Focus on developing shared decision making with the integrated team.
  • Provider capacity for transformational change.
  • Challenges from the private provider about reductions in activity.
  • It would have been useful to have earlier discussions about the reallocation of orthopaedic capacity following the reduction in activity.

With thanks to:

  • Dave Whatton, Senior Commissioning Manager, Walsall CCG
  • Lucy Heath, Delivery Partner, RightCare

For more information please contact rightcare@nhs.net